Navigation-guided neuroendoscopic removal of an intracranial migratory pellet from the thalamus of a 4-year-old girl

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  • 1 School of Medicine, Mercer University, Macon; and
  • | 2 Neurological and Spine Institute of Savannah, Georgia
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Extraction of a bullet fragment seated in deep brain parenchyma utilizing a neuroendoscope has not been previously reported in the literature. The authors report the case of a 4-year-old patient who presented after a pellet gun injury with a projectile located 6 cm intracranially and lodged within the posterior thalamus and near the posterior limb of the internal capsule. Initial operative repair included repair of a CSF leak with duraplasty, minimal brain debridement, and elevation of a depressed skull fracture. Subsequent CT at 2 months postoperatively revealed migration of the deep intracranial pellet. This finding correlated with intermittent worsening neurological symptoms and signs. A rigid 3-mm neuroendoscope with CT stereotactic navigation was then used to remove the pellet fragment from the thalamus. The patient returned home with alleviation of clinical symptoms and an uneventful postoperative recovery. This case demonstrates that navigation-guided neuroendoscopy can be successfully used to remove projectile fragments from deep brain structures, especially when the migration is along the initial path of the bullet. This technique represents another low-risk curative option in the management of retained bullet fragments in gunshot wound injuries to the head.

Extraction of a bullet fragment seated in deep brain parenchyma utilizing a neuroendoscope has not been previously reported in the literature. The authors report the case of a 4-year-old patient who presented after a pellet gun injury with a projectile located 6 cm intracranially and lodged within the posterior thalamus and near the posterior limb of the internal capsule. Initial operative repair included repair of a CSF leak with duraplasty, minimal brain debridement, and elevation of a depressed skull fracture. Subsequent CT at 2 months postoperatively revealed migration of the deep intracranial pellet. This finding correlated with intermittent worsening neurological symptoms and signs. A rigid 3-mm neuroendoscope with CT stereotactic navigation was then used to remove the pellet fragment from the thalamus. The patient returned home with alleviation of clinical symptoms and an uneventful postoperative recovery. This case demonstrates that navigation-guided neuroendoscopy can be successfully used to remove projectile fragments from deep brain structures, especially when the migration is along the initial path of the bullet. This technique represents another low-risk curative option in the management of retained bullet fragments in gunshot wound injuries to the head.

Penetrating head injuries by nonpowder guns, also known as spring- and gas-powered guns, are being increasingly recognized as a potential cause of serious injury in children. Injuries sustained from nonpowder guns are comparable to injuries from lower-velocity firearms,1,2 and many fire ammunition at a similar velocity to that of a 0.22-caliber firearm.3 Pediatric patients are especially vulnerable to these injuries due to a thin skull, as well as pediatric patients’ thinner overlying soft tissues when compared to adult soft tissue.4 Projectile injuries are typically treated by a craniotomy for the purpose of debridement, removal of blood clots, and excision of pellets when they are seated at locations in close proximity to the operative site.5,29 However, foreign bodies located at deeper structures prove more challenging to retrieve and efforts at excision could potentially worsen neurological symptoms and damage vascular structures. In this paper, we describe the first navigation-guided neuroendoscopic pellet retrieval from the deep thalamus in a pediatric patient. We present the clinical, operative, and radiographic findings for future replication of this procedure.

Case Report

History and Examination

A 4-year-old right-handed girl with a past medical history of asthma presented after being accidentally shot by a pellet rifle while playing with her 12-year-old brother at home. The pellet entered above her left ear, and the patient was reported to have a brief loss of consciousness. Upon presentation to the hospital, the child had mild right hemiparesis and significant apraxia of the right hand. Speech difficulties were present as well, and this became more evident during her hospitalization.

An initial noncontrast CT scan of the head was performed, followed by a CT angiography scan to evaluate for vascular injury. Imaging revealed that the pellet penetrated the skull just above and behind the left ear at the left temporoparietal bone junction and entered the parietal lobe near the supramarginal gyrus, missing the sylvian fissure, insular cortex, and ventricular system. There was no visible exit site, and pellet fragments were as deep as 6 cm within the brain (Fig. 1A). The larger pellet fragment was found seated in her left posterior thalamus and close to the posterior limb of the left internal capsule on initial radiographic imaging. There was surrounding edema in the brain tissue. A ballistic tract was found to extend from the soft tissue overlying the left temporoparietal skull to the thalamus, with another metallic fragment density found within the tract. In addition, multiple bone fragments were found to extend along the tract. No evidence of vascular injury was found.

FIG. 1.
FIG. 1.

Sequential CT imaging of pellet migration. Noncontrast axial head CT series revealed the fragments at initial presentation (A), migration of fragments on imaging 2 months after the initial presentation (B), return of the larger fragment to its original 6-cm depth intracranially upon preoperative stereotactic navigation CT protocol (C), and the absence of pellet fragments postoperatively (D). Figure is available in color online only.

Initial Operation

An initial neurosurgical operation was indicated as the patient developed a CSF leak at the pellet entry site, which persisted despite suturing of the scalp laceration. A left temporoparietal craniotomy was performed for repair of the CSF leak with duraplasty, utilizing a periosteal autograft. There was minimal brain debridement needed of the contused tissue. The small depressed skull fracture was repaired as well.

The pellet fragments were not removed at that time due to the deemed high risk of further neurological injury and damage to vascular structures. Her weakness did improve and she began speaking more, but her right-hand apraxia persisted.

At 2 months after the initial presentation, the patient’s mother was convinced that her daughter had progressively worsening right-hand function and speech difficulties. There was no clear clinical history of seizure-like activity. A follow-up CT scan without contrast at that time revealed that the deep pellet fragment had migrated 4 cm lateral from its original 6-cm location in the thalamus more superficially to the left parietal lobe, resting approximately 2 cm intracranially (Fig. 1B). It also demonstrated the second pellet fragment 1.3 cm deep, and slightly more superficial than the larger migrated fragment.

Extensive discussions were undertaken with the family regarding the indication for another surgery. The mother was strong in her opinion of the daughter’s declining function, and we were convinced that the migrating pellet fragment was likely the cause. In addition, we felt uncomfortable with observation alone given the potential for further neurological worsening or even a catastrophic event such as a stroke or intracranial hemorrhage. Therefore, it was decided to proceed with surgical removal of the pellet fragments.

Second Operation

On the morning of surgery, new preoperative navigational CT head imaging revealed that the larger pellet fragment had migrated back to its original location in the thalamus, 6 cm deep intracranially (Fig. 1C). After discussing the new imaging results with the family, a plan was formulated to proceed with a temporoparietal craniotomy to remove the superficial 1.3-cm-deep pellet fragment and to perform exploratory neuroendoscopy to determine if the migratory 6-cm deeper pellet fragment could be removed. We remained reluctant to proceed with an aggressive open retrieval of the 6-cm-deep fragment given the higher risk. If there was no reasonable path found for the neuroendoscope, or if attempting to remove the fragment appeared unsafe, then excision of the deeper fragment would be aborted. The family was in full agreement for the team to use our best judgment at the time of surgery.

During the procedure, the superficial pellet fragment was retrieved without complication. Intraoperative fluoroscopic imaging confirmed the location of the deep-seated pellet fragment. The exploration proceeded with the use of a 3-mm rigid intraventricular neuroendoscopic system (Pediatric, Aesculap, Inc.; Fig. 2 left). Warm lactated Ringer’s solution was attached to one of the working ports of the neuroendoscope. A universal navigator adapter clamp (Stryker nGenius Tracker, Stryker Corp.) was placed on the handle of the neuroendoscope and then the tip was registered with the CT stereotactic navigation system (Stryker NAV3i computer-assisted surgical system). The deep pellet fragment was set as the stereotactic target, and the entry was set at the cortical entry of the ballistic pathway. A 10-Fr sheath was placed within the cortical tissue 1.5 cm deep and secured with Telfa strips and cottonoids, using the same trajectory as the original pellet path. The neuroendoscope was advanced, and fortunately a well-demarcated open path accommodated the scope without any difficulties. Ongoing irrigation with lactated Ringer’s solution further kept the path dilated for navigation. Upon entry 5 cm deep into the intraparenchymal path, the pellet fragment was visualized.

FIG. 2.
FIG. 2.

Intraoperative endoscopic imaging of the pellet’s ballistic tract (left) and the pellet’s location after the endoscope was manipulated 5 cm intracranially (right). Figure is available in color online only.

Neuroendoscopic cupped forceps were used to remove the fragment (Fig. 2 right). The fragment was successfully removed with one attempt, and there was no further tissue trauma with the approach (Video 1).

VIDEO 1. Clip showing intraoperative endoscopic pellet removal. The endoscope was advanced through a well-demarcated path while utilizing irrigation to maintain dilation of the path for navigation. The pellet fragment was visualized upon entry, 5 cm deep to the cranium, and the pellet fragment was removed successfully with cupped forceps. Copyright Julian L. Gendreau. Published with permission. Click here to view.

No entry into the ventricular system occurred. The smaller bone fragments were not seen and further exploration was considered of little benefit. The dura was primarily closed, and the cranial bone flap was replaced with suture. There was no significant bleeding or swelling during the operation.

Postoperative Course

The patient did remarkably well postoperatively. Her postoperative CT scan showed successful excision of all metal pellet fragments without significant bleeding or edema (Fig. 1D). Upon her subsequent clinical visits, her right-hand apraxia improved and the parents reported improvement in her speech. She continues to do well in physical and speech therapy.

Discussion

Injury from nonpowder gun–induced trauma is becoming increasingly prevalent in the US. Each year, an estimated 3.2 million nonpowder guns are sold,6 and in 2017 the National Electronic Injury Surveillance System7 estimated that a total of 18,652 nonpowder gun injuries occurred in the population. The most commonly reported locations of injury include the head, eye, brain, and neck. These injuries have the potential to cause significant morbidity and even death in children.8,9 With intracranial penetration of projectiles found in as many as 19% of patients with nonpowder gun injury, the literature has reported rates ranging from 43% to 56.8% of patients developing permanent neurological injury such as diplopia, visual field deficits, epilepsy, cognitive deficits, and blindness.1,2,9 Additionally, cases of infectious meningitis, pellet migration to the thoracic spine and pulmonary artery, and death due to subarachnoid hemorrhage after basilar artery injury have been reported.10–13

In patients with intracranial penetration there is also risk of projectile migration. With the first reported case in 1916, cases of migration are mentioned sporadically throughout the literature; one study found the prevalence to be 4.2% of patients with intracranial gunshot wounds with projectile migration within the week following injury.14,15 Migration is more likely to occur when projectiles are located within the ventricles, subarachnoid space, or necrotic liquefied tissue, or when the projectile remains in its projectile tract.16 Softening of surrounding cerebral white matter after injury and the relatively higher specific gravity of the projectile compared to the surrounding cerebral matter are believed to contribute to migration.17

In this case, it was confirmed at surgery that a well-demarcated path existed after the initial injury, which allowed the pellet fragment to move freely and frequently. There was a hematoma that existed in the path found upon initial CT imaging, and there was also a CSF leak suggesting CSF communication. The authors believe that both the hematoma and the CSF communication resulted in blood degradation and cellular necrosis, which contributed to leukomalacia and the evolving cavity along the ballistic tract. This high degree of mobility of an intracranial foreign body within the brain parenchyma has not been previously reported in the literature.

Proper management of these patients with migrating intracranial foreign bodies remains controversial, as serious neurological deficits have been reported from attempts at operative resection.18–20 However, cases with minimal to no neurological deficits are also documented.5,21,22

Up to 71% of patients with intracranial injury from nonpowder guns undergo operative intervention.2 If surgery is judged to be necessary by an experienced neurosurgeon, then treatment should begin with meticulous debridement of both the scalp and skull. A craniotomy should be performed, with utilization of suction and irrigation to debride the cortex of projectile fragments, bone fragments, and necrotic tissue.23 Some authors have used radiography or CT imaging in the operating room to confirm the site of the bullet, even before head positioning.5,17 Others have used intraoperative ultrasonography to assist in localization of the projectile.14 When the bullet fragments are superficial and accessible in the brain, this process can be performed with minimal risk. However, when projectiles are seated in deeper areas, there is risk of damaging nearby subcortical nuclei, neuronal tracts, and vascular structures. There is also risk of inoculating infection. In these situations of high risk, minimally invasive treatment using navigation-assisted endoscopic removal has been suggested previously in the literature and is potentially a viable option.15

To date, the literature has reported few successful cases of neuroendoscopic foreign body excision in certain areas of the brain and other locations of injury to the head. Nasal endoscopy was used to remove a foreign body from the lower anterior cranial fossa with slight clinical complications.24 A standard neuroendoscopic third ventriculostomy approach has been used to excise a foreign object from the third ventricle.25 A pellet lodged in the left frontal lobe of a patient has been recovered with a reported uneventful postoperative recovery.26 In addition, there are numerous cases of successful pellet excision from the orbital cavities and sphenoid sinuses.15,27,28 However, no cases are documented that have demonstrated the successful use of neuroendoscopy to retrieve foreign bodies seated in the deep thalamus of the brain.

Our case was fortunate that the patient had a good postoperative outcome with alleviation of her neurological symptoms. Of note, it is worth explaining the mechanism of her injuries when they were present. The mild hemiparesis was likely from injury to the posterior limb of the internal capsule, her apraxia from injury to part of the supramarginal gyrus of the dominant parietal lobe, and her speech difficulties from injury to the dominant parietal lobe as well.

This case provides evidence that navigation-guided rigid neuroendoscopy can be successfully used to retrieve deep-seated projectiles located in brain structures such as the thalamus. We propose this would be the best option for deep bullet fragments that migrate along the ballistic pathway of the projectile.

Acknowledgments

We would like to acknowledge Tanner Forester and Andrew DuRant for their assistance with the Stryker surgical products.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Thompson, Little, Andrews. Acquisition of data: Duddleston. Drafting the article: all authors. Critically revising the article: Duddleston, Gendreau, Little, Andrews. Administrative/technical/material support: Thompson. Study supervision: Thompson.

Supplemental Information

References

  • 1

    Bond SJ, Schnier GC, Miller FB. Air-powered guns: too much firepower to be a toy. J Trauma. 1996;41(4):674678.

  • 2

    Kumar R, Kumar R, Mallory GW, et al. Penetrating head injuries in children due to BB and pellet guns: a poorly recognized public health risk. J Neurosurg Pediatr. 2016;17(2):215221.

    • Search Google Scholar
    • Export Citation
  • 3

    Bratton SL, Dowd MD, Brogan TV, Hegenbarth MA. Serious and fatal air gun injuries: more than meets the eye. Pediatrics. 1997;100(4):609612.

    • Search Google Scholar
    • Export Citation
  • 4

    Margulies SS, Thibault KL. Infant skull and suture properties: measurements and implications for mechanisms of pediatric brain injury. J Biomech Eng. 2000;122(4):364371.

    • Search Google Scholar
    • Export Citation
  • 5

    Karabagli H. Spontaneous movement of bullets in the interhemispheric region. Pediatr Neurosurg. 2005;41(3):148150.

  • 6

    Nguyen MH, Annest JL, Mercy JA, et al. Trends in BB/pellet gun injuries in children and teenagers in the United States, 1985-99. Inj Prev. 2002;8(3):185191.

    • Search Google Scholar
    • Export Citation
  • 7

    United States Consumer Product Safety Commission. NEISS Data Highlights-2017. Accessed May 1, 2020. https://www.cpsc.gov/s3fs-public/2017-Neiss-data-highlights.pdf?3i3POG9cN.rIyu2ggrsUkD1XU_zoiFRP

    • Search Google Scholar
    • Export Citation
  • 8

    Christoffel KK, Tanz R, Sagerman S, Hahn Y. Childhood injuries caused by nonpowder firearms. Am J Dis Child. 1984;138(6):557561.

  • 9

    O’Neill PJ, Lumpkin MF, Clapp B, et al. Significant pediatric morbidity and mortality from intracranial ballistic injuries caused by nonpowder gunshot wounds. A case series. Pediatr Neurosurg. 2009;45(3):205209.

    • Search Google Scholar
    • Export Citation
  • 10

    DeWeese WO, LeBlanc HJ, Kline DG. Pellet-gun brain wound complicated by Clostridium Perfringens meningitis. Surg Neurol. 1976;5(4):253254.

    • Search Google Scholar
    • Export Citation
  • 11

    Lough EG, Glover B, Brown AL. An unusual case of air rifle pellet migration from the brain to the thoracic spine. Am Surg. 2013;79(1):E33E34.

    • Search Google Scholar
    • Export Citation
  • 12

    Nehme AE. Intracranial bullet migrating to pulmonary artery. J Trauma. 1980;20(4):344346.

  • 13

    Tokdemir M, Türkçüoğlu P, Kafadar H, Türkoğlu A. Sudden death following periorbital pellet injury. Brain Inj. 2007;21(9):997999.

    • Search Google Scholar
    • Export Citation
  • 14

    Rapp LG, Arce CA, McKenzie R, et al. Incidence of intracranial bullet fragment migration. Neurol Res. 1999;21(5):475480.

  • 15

    Verhaeghe W, Schepers S, Sun Y, et al. Removal of a low-velocity projectile from the base of the sphenoid sinus using navigation-guided endoscopy. J Craniofac Surg. 2012;23(2):472476.

    • Search Google Scholar
    • Export Citation
  • 16

    Fujimoto Y, Cabrera HT, Pahl FH, et al. Spontaneous migration of a bullet in the cerebellum—case report. Neurol Med Chir (Tokyo). 2001;41(10):499501.

    • Search Google Scholar
    • Export Citation
  • 17

    Milhorat TH, Elowitz EH, Johnson RW, Miller JI. Spontaneous movement of bullets in the brain. Neurosurgery. 1993;32(1):140143.

  • 18

    Liebeskind AL, Anderson RD, Schechter MM. Spontaneous movement of an intracranial missile. Neuroradiology. 1973;5(3):129132.

  • 19

    Sherman IJ. Brass foreign body in the brain stem. A case report. J Neurosurg. 1960;17:483485.

  • 20

    Sternbergh WC Jr, Watts C, Clark K. Bullet within the fourth ventricle. Case report. J Neurosurg. 1971;34(6):805807.

  • 21

    Koçak A, Özer MH. Intracranial migrating bullet. Am J Forensic Med Pathol. 2004;25(3):246250.

  • 22

    Rammo RA, DeFazio MV, Bullock MR. Management of migrating intracranial bullets: lessons learned from surviving an AK-47 bullet through the lateral brainstem. World Neurosurg. 2012;77(3-4):591.e19591.e24.

    • Search Google Scholar
    • Export Citation
  • 23

    Rosenfeld JV, Bell RS, Armonda R. Current concepts in penetrating and blast injury to the central nervous system. World J Surg. 2015;39(6):13521362.

    • Search Google Scholar
    • Export Citation
  • 24

    Thomas S, Daudia A, Jones NS. Endoscopic removal of foreign body from the anterior cranial fossa. J Laryngol Otol. 2007;121(8):794795.

    • Search Google Scholar
    • Export Citation
  • 25

    Aydoseli A, Unal TC, Aras Y, et al. Endoscopic removal of a bullet that migrated to the third ventricle causing hydrocephalus. World Neurosurg. 2017;105:1038.e111038.e16.

    • Search Google Scholar
    • Export Citation
  • 26

    Mohanty A, Manwaring K. Endoscopically assisted retrieval of an intracranial air gun pellet. Pediatr Neurosurg. 2002;37(1):5255.

  • 27

    Feichtinger M, Zemann W, Kärcher H. Removal of a pellet from the left orbital cavity by image-guided endoscopic navigation. Int J Oral Maxillofac Surg. 2007;36(4):358361.

    • Search Google Scholar
    • Export Citation
  • 28

    Strek P, Zagólski O, Składzień J. Endoscopic removal of air gun pellet in the sphenoid sinus. B-ENT. 2005;1(4):205207.

  • 29

    Vilvandré BG, Morgan JD. Movements of foreign bodies in the brain. Arch Radiol Electrother. 1916;21:2227.

Illustration from Guida et al. (pp 346–352). Copyright Lelio Guida. Published with permission.

Contributor Notes

Correspondence Willard D. Thompson Jr.: Neurological and Spine Institute of Savannah, GA. dr.thompson@neurosav.com.

INCLUDE WHEN CITING Published online July 10, 2020; DOI: 10.3171/2020.4.PEDS19606.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • View in gallery

    Sequential CT imaging of pellet migration. Noncontrast axial head CT series revealed the fragments at initial presentation (A), migration of fragments on imaging 2 months after the initial presentation (B), return of the larger fragment to its original 6-cm depth intracranially upon preoperative stereotactic navigation CT protocol (C), and the absence of pellet fragments postoperatively (D). Figure is available in color online only.

  • View in gallery

    Intraoperative endoscopic imaging of the pellet’s ballistic tract (left) and the pellet’s location after the endoscope was manipulated 5 cm intracranially (right). Figure is available in color online only.

  • 1

    Bond SJ, Schnier GC, Miller FB. Air-powered guns: too much firepower to be a toy. J Trauma. 1996;41(4):674678.

  • 2

    Kumar R, Kumar R, Mallory GW, et al. Penetrating head injuries in children due to BB and pellet guns: a poorly recognized public health risk. J Neurosurg Pediatr. 2016;17(2):215221.

    • Search Google Scholar
    • Export Citation
  • 3

    Bratton SL, Dowd MD, Brogan TV, Hegenbarth MA. Serious and fatal air gun injuries: more than meets the eye. Pediatrics. 1997;100(4):609612.

    • Search Google Scholar
    • Export Citation
  • 4

    Margulies SS, Thibault KL. Infant skull and suture properties: measurements and implications for mechanisms of pediatric brain injury. J Biomech Eng. 2000;122(4):364371.

    • Search Google Scholar
    • Export Citation
  • 5

    Karabagli H. Spontaneous movement of bullets in the interhemispheric region. Pediatr Neurosurg. 2005;41(3):148150.

  • 6

    Nguyen MH, Annest JL, Mercy JA, et al. Trends in BB/pellet gun injuries in children and teenagers in the United States, 1985-99. Inj Prev. 2002;8(3):185191.

    • Search Google Scholar
    • Export Citation
  • 7

    United States Consumer Product Safety Commission. NEISS Data Highlights-2017. Accessed May 1, 2020. https://www.cpsc.gov/s3fs-public/2017-Neiss-data-highlights.pdf?3i3POG9cN.rIyu2ggrsUkD1XU_zoiFRP

    • Search Google Scholar
    • Export Citation
  • 8

    Christoffel KK, Tanz R, Sagerman S, Hahn Y. Childhood injuries caused by nonpowder firearms. Am J Dis Child. 1984;138(6):557561.

  • 9

    O’Neill PJ, Lumpkin MF, Clapp B, et al. Significant pediatric morbidity and mortality from intracranial ballistic injuries caused by nonpowder gunshot wounds. A case series. Pediatr Neurosurg. 2009;45(3):205209.

    • Search Google Scholar
    • Export Citation
  • 10

    DeWeese WO, LeBlanc HJ, Kline DG. Pellet-gun brain wound complicated by Clostridium Perfringens meningitis. Surg Neurol. 1976;5(4):253254.

    • Search Google Scholar
    • Export Citation
  • 11

    Lough EG, Glover B, Brown AL. An unusual case of air rifle pellet migration from the brain to the thoracic spine. Am Surg. 2013;79(1):E33E34.

    • Search Google Scholar
    • Export Citation
  • 12

    Nehme AE. Intracranial bullet migrating to pulmonary artery. J Trauma. 1980;20(4):344346.

  • 13

    Tokdemir M, Türkçüoğlu P, Kafadar H, Türkoğlu A. Sudden death following periorbital pellet injury. Brain Inj. 2007;21(9):997999.

    • Search Google Scholar
    • Export Citation
  • 14

    Rapp LG, Arce CA, McKenzie R, et al. Incidence of intracranial bullet fragment migration. Neurol Res. 1999;21(5):475480.

  • 15

    Verhaeghe W, Schepers S, Sun Y, et al. Removal of a low-velocity projectile from the base of the sphenoid sinus using navigation-guided endoscopy. J Craniofac Surg. 2012;23(2):472476.

    • Search Google Scholar
    • Export Citation
  • 16

    Fujimoto Y, Cabrera HT, Pahl FH, et al. Spontaneous migration of a bullet in the cerebellum—case report. Neurol Med Chir (Tokyo). 2001;41(10):499501.

    • Search Google Scholar
    • Export Citation
  • 17

    Milhorat TH, Elowitz EH, Johnson RW, Miller JI. Spontaneous movement of bullets in the brain. Neurosurgery. 1993;32(1):140143.

  • 18

    Liebeskind AL, Anderson RD, Schechter MM. Spontaneous movement of an intracranial missile. Neuroradiology. 1973;5(3):129132.

  • 19

    Sherman IJ. Brass foreign body in the brain stem. A case report. J Neurosurg. 1960;17:483485.

  • 20

    Sternbergh WC Jr, Watts C, Clark K. Bullet within the fourth ventricle. Case report. J Neurosurg. 1971;34(6):805807.

  • 21

    Koçak A, Özer MH. Intracranial migrating bullet. Am J Forensic Med Pathol. 2004;25(3):246250.

  • 22

    Rammo RA, DeFazio MV, Bullock MR. Management of migrating intracranial bullets: lessons learned from surviving an AK-47 bullet through the lateral brainstem. World Neurosurg. 2012;77(3-4):591.e19591.e24.

    • Search Google Scholar
    • Export Citation
  • 23

    Rosenfeld JV, Bell RS, Armonda R. Current concepts in penetrating and blast injury to the central nervous system. World J Surg. 2015;39(6):13521362.

    • Search Google Scholar
    • Export Citation
  • 24

    Thomas S, Daudia A, Jones NS. Endoscopic removal of foreign body from the anterior cranial fossa. J Laryngol Otol. 2007;121(8):794795.

    • Search Google Scholar
    • Export Citation
  • 25

    Aydoseli A, Unal TC, Aras Y, et al. Endoscopic removal of a bullet that migrated to the third ventricle causing hydrocephalus. World Neurosurg. 2017;105:1038.e111038.e16.

    • Search Google Scholar
    • Export Citation
  • 26

    Mohanty A, Manwaring K. Endoscopically assisted retrieval of an intracranial air gun pellet. Pediatr Neurosurg. 2002;37(1):5255.

  • 27

    Feichtinger M, Zemann W, Kärcher H. Removal of a pellet from the left orbital cavity by image-guided endoscopic navigation. Int J Oral Maxillofac Surg. 2007;36(4):358361.

    • Search Google Scholar
    • Export Citation
  • 28

    Strek P, Zagólski O, Składzień J. Endoscopic removal of air gun pellet in the sphenoid sinus. B-ENT. 2005;1(4):205207.

  • 29

    Vilvandré BG, Morgan JD. Movements of foreign bodies in the brain. Arch Radiol Electrother. 1916;21:2227.

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